Bone marrow-derived mesenchymal stem cells as a source of neural progenitors

ABSTRACT

Methods are provided for treating and/or reducing the severity of multiple sclerosis in a human, by administering autologous mesenchymal stem cell-derived neural precursors. Also described is an in vitro method for differentiating mesenchymal stem-cell derived neural precursor oligodendroglial and neuronal cell types.

CROSS REFERENCE TO RELATED APPLICATION

The present application is a continuation application of U.S. Patentapplication Ser. No. 12/377,900, filed Feb. 18, 2009, which is thenational phase under §371 of International Application No.PCT/US07/023184, filed Nov. 2, 2007, which claims benefit of U.S.Provisional Patent Application No. 60/856,515, filed Nov. 3, 2006.

FIELD OF THE INVENTION

The present invention relates to the use of bone marrow-derivedmesenchymal stem cells as a source of neural progenitors for use inautologous stem cell therapy of multiple sclerosis.

BACKGROUND

Multiple sclerosis (MS) is a chronic human autoimmune disease of thecentral nervous system (CNS) that affects 600,000 Americans and 2.5million individuals worldwide. MS is most often diagnosed between theages of 20 and 50 and is second only to trauma in causing neurologicaldisability in young adults. The disease usually starts between 20 to 40years of age and there are two major forms. Relapsing-remitting MS(RR-MS) is the most frequent form (85%-90%) and affects women abouttwice as often as men. Most RR-MS patients later develop the secondmajor form known as secondary progressive MS (SP-MS). About 10%-15% ofpatients show a steady progression following disease onset with theabsence of relapses, termed primary progressive PP-MS. (Sospedra, etal., Annu Rev Immunol 23, 683 [2005]). MS is a highly heterogeneousdisease where every patient differs in clinical presentation andresponse to treatments.

Although the exact cause of MS is unknown, pathologically there isinflammation-induced destruction of the myelin sheath that surroundsaxons in the brain and spinal cord leading to decreased nerveconduction. Clinically, the loss of myelin leads to a variety ofneurological symptoms and, in some patients, major disability. In mostpatients with relapsing-remitting disease, inflammation-induceddemyelination is spontaneously repaired by oligodendrocytes, the cellsin the brain that produce and maintain myelin. Acute inflammation andchronic demyelination eventually lead to destruction of oligodendrocytesand axonal loss. The secondary progressive phase of MS is characterizedby neurodegeneration and treatment-resistant functional deterioration.

Current treatment options for MS are immunomodulatory andimmunosuppressive therapies that are mostly effective during theinflammation-mediated relapsing-remitting phase of MS. These therapiesare only partially effective in slowing down the progressive phase ofMS, which may be largely neurodegenerative. There is an urgent need fortherapies that can stop or reverse the progression of MS throughstrategies involving neural repair and regeneration.

Stem cell therapies hold much promise for regenerative medicine. Stemcells have the potential to develop into many different cell types inthe body. Stem cells can theoretically divide without limit to replenishcells in need of repair. There are different types of stem cells withvarying ranges of commitment options. Embryonic stem cells hold greatpotential for regenerative medicine, however, they have a number ofdisadvantages including the possibility of transplant rejection andpossible teratoma formation if the cells are not properly differentiatedprior to transplantation. Adult stem cells such as neural stem cells(NSC) and oligodendrocyte precursor cells (OPC) have a more restricteddevelopmental potential than embryonic stem cells and generallydifferentiate along their lineage of origin. While adult neural stemcells also represent a promising treatment option for neurodegenerativedisorders, there are a number of disadvantages, including difficulty ofisolation, limited expansion capability, and immune rejection oftransplanted donor cells.

Bone marrow-derived mesenchymal stem cells (MSCs) are another type ofadult stem cell that differentiates into non-hematopoietic tissuesincluding osteoblasts, adipocytes, chondrocytes, and myoblasts (Ferrari,et. al., Science 279:1528-1530 [1998]; Pittenger, et. al., Science287:143-147 [1999]; Prockop, et. al., Science 276:71-74 [1997]). The useof bone marrow-derived stem cells has many therapeutic advantages. Bonemarrow is an easily accessible and autologous source of stem cells, thuseliminating the risk of rejection. Since mesenchymal stem cells haveenormous ex vivo expansion capability, it is possible to expand a smallpopulation of cells into enough cells for clinical application.

MSCs have a number of remarkable in vitro characteristics, making them avery attractive candidate for neurodegenerative and immunologicaldisorders.

MSCs exhibit differentiation plasticity, meaning that they are capableof differentiating along lineages other than their tissue of origin(Jiang, et. al., Nature 418:41-49 [2002]; Woodbury, et. al., J. NeurosciRes 69:908-917 [2002]). MSCs are capable of forming cells with neuronaland glial phenotypes in vitro (Black et. al., Blood Cells Mol Dis 27:632-636 [2001]; Deng et. al., Biochem Biophys Res Commun 282: 148-152[2001]; Hermann, et. al., J. Cell Sci 117:4411-4422 [2004];Sanchez-Ramos, et. al., Exp. Neurol 164: 247-256 [2000]; Suzuki, et.al., Biochem Biophys Res Commun 322: 918-922 [2004]; Woobury, et. al., JNeurosci Res 61: 364-370 [2000]). MSCs incubated in the presence ofgrowth factors basic fibroblast growth factor (bFGF) and epidermalgrowth factor (EGF) displayed a neural stem cell morphology withincreased expression of neural stem cell markers (Hermann, et. al., JCell Sci 117: 4411-4422 [2004]). These studies raise the possibilitythat MSCs may be capable of cell replacement in the damaged brain andspinal cord.

MSCs have an immunoregulatory function. It has been demonstrated thatMSCs can suppress T, B, NK, and dendritic cell activation andproliferation (Uccelli, et. el., Expert Opin Biol Ther 6: 17-22 [2006]).These anti-inflammatory properties of MSCs suggest a possible clinicalapplication for immune-mediated disease.

MSCs can promote the genesis of neurons and oligodendrocytes from neuralstem cells (Bai, et. al., Neurochem Res 32: 353-362 [2007]; Rivera, et.al. Stem Cell 24: 2209-2219 [2006]). These recent studies show that MSCssecrete trophic factors that influence neural stem cell progeny, whichmay have clinical implications in enhancing recovery after a wide rangeof CNS injuries.

The findings that MSCs can generate neural stem cell-like cells thatexpress neural stem cell markers (Hermann, et. al., J Cell Sci 117:4411-4422 [2004]) suggest that MSC-derived neural precursors may be amore potent source for therapeutic use in the CNS. MSCs cultured inneural stem cell-specific media (serum free media containing 20 ng/ml ofboth EGF and bFGF) exhibited neurosphere morphology with an increase inneural stem cell marker genes (Nestin), glial genes (GFAP, MBP) andneuronal genes (Map2, Neurofilament, Tyrosine hydroxylase, voltagedependent K+ channels) (Hermann, et. al., J Cell Sci 117: 4411-4422[2004]; Hermann, et. al., J Neurosci Res 83: 1502-1514 [2006]; Mareschi,et. al., Exp Hematol 34: 1563-1572 [2006]). In comparing differentculture conditions to convert MSCs to neural precursors, one study foundthat MSCs cultured in Neural Progenitor Maintenance Media (NPMM, Lonza)acquired the morphological characteristics, neural markers, andelectrophysiological properties suggestive of neural differentiation(Mareschi, et. al., Exp Hematol 34: 1563-1572 [2006]).

Use of Mesenchymal Stem Cells in Neurological Diseases

A number of clinical trials have analyzed the safety and therapeuticbenefit of MSCs. Several hundred patients have been infused withallogeneic HLA-matched MSCs in the context of hematopoietic stem-celltransplant for malignancy or inborn metabolic disease (Lazarus, et. al.,Biol Blood Marrow Transplant 11: 389-398 [2005]; Le Blanc, et. al., BiolBlood Marrow Transplant 11: 321-334 [2005]). Severe graft vs. hostdisease (GvHD) was reversed upon infusion of donor-derived MSCs (LeBlanc et. al., Lancet 363: 1439-1441 [2004]). In these studies, infusionof approximately 1-2 million cells/kg MSCs is well tolerated with noside effects. Thus, initial clinical trial data suggests that MSC-basedtherapies hold much promise as immune modulators, and additional PhaseI/II trials studying the effects of the role of MSCs in the treatment ofGvHD are ongoing (Giordano, et. al., J Cell Physiol 211: 27-35 [2007]).Furthermore, clinical trials examining MSCs in osteogenesis imperfecta(Horwitz, et. al., Proc Natl Acad Sci USA 99: 8932-8937 [2002]; LeBlanc, et. al., Transplantation 79: 1607-1614 [2005]), myocardialinfarct (Chen, et. al., Am J Cardiol 94: 92-95 [2004]; Katritsis et.al., Catherter Cardiovas Interv 65: 321-329 [2005]), and stroke (Bang,et. al., Ann Neurol 57: 874-882 [2005]) have shown safety and efficacyfor the treatment of these diseases as well.

In a recent clinical trial in Italy (Mazzini, et. al., Amyotroph LateralScler Other Motor Neuron Disord 4: 158-161 [2003]; Mazzini, et. al.,Neurol Res 28: 523-526 [2006]; Mazzini, et. al., Neurol Sci [2007]),autologous bone marrow-derived MSCs were transplanted directly into thespinal cord of nine patients with amyotrophic lateral sclerosis (ALS), adegenerative motor neuron disease. Intraspinal transplantation of anaverage of 32 million autologous MSCs was safe and well tolerated by ALSpatients, within a follow-up period of 4 years. Minor adverse eventswere intercostal pain irradiation and leg sensory dysesthesia, whichdisappeared after 6 weeks. In 5 of the patients receiving autologous MSCtransplantation, there was a significant slowing of the linear declinein the ALS-functional rating scale (Mazzini, et. al., Neurol Res 28:523-526 [2006]). Given the progressive nature of this disease, thesefindings suggest a clinical benefit of MSC transplantation and warrantfurther trials. The encouraging clinical results for autologous MSCtransplantation in ALS and the safety and tolerability observed in the4-year follow-up suggest that a similar approach could be taken to treatother neurodegenerative disorders such as MS.

Use of Mesenchymal Stem Cells in MS

Based on the preclinical data demonstrating peripheral immunosuppressionin EAE, a current phase I/IIA research study is taking place at theUniversity of Cambridge in Cambridge, England. The study aims toinvestigate the safety of intravenous administration of autologous MSCsin patients with multiple sclerosis. There are 20 patients enrolled inthe study, and the dosage will be 2 million cells/kg(http://clinicaltrials.gov/ct/show/NCT00395200;jsessionid=F5A5DF2968E1567A594549F1CCE4B7EF?order=14).

In a recent pilot study conducted in Iran, human autologous MSCs wereinjected intrathecally in ten primary progressive and secondaryprogressive MS patients (Mohyeddin, et. al., Iran J Immunol 4: 50-572007]). Researchers injected an average of 8.73 million cells. Thehighest dose was 13.2 million cells and the lowest dose was 2.5 millioncells. Patients were followed for an average of nineteen months aftertreatment, with monthly follow-up exams and an MRI 12 months afterintrathecal injection of autologous MSCs. Patients were evaluated forchanges in EDSS score, changes in the number and size of lesions on anMRI, and subjective improvement. Researchers found that intrathecalautologous MSC transplantation was safe and well tolerated with sideeffects related to the intrathecal injection procedure (e.g. headache).Two patients contracted iatrogenic meningitis and both patients weretreated successfully with antibiotics. They also noted that the therapywas associated with some improvement. One patient experienced a decreasein EDSS score. Four patients showed improvement in daily functions withno change in EDSS score. Five patients experienced an increase in EDSSscore, and all five reported subjective improvement within three monthsof treatment. Researchers concluded that autologous intrathecal MSCinjection is a safe and promising treatment for MS patients.

The use of MSC-derived neural precursors has not hereto before beenreported for administration to humans.

SUMMARY OF THE INVENTION

The invention provides methods for the in vitro differentiation ofmesenchymal stem cell-derived neural precursor cells. The inventionfurther provides methods for treating and/or reducing the severity ofmultiple sclerosis in a human by administering mesenchymal stemcell-derived neural precursors to patient afflicted with multiplesclerosis.

The mesenchymal stem cell-derived neural precursor cells according tothe present invention are formed by culturing the mesenchymal stem cellsin a neural progenitor basal medium followed by plating the cells andculturing in basic fibroblast growth factor (bFGF). The neural precursorcells are then labeled, such as via fluorescent immunocytochemistry, foridentification. The neural precursor cells include oligodendroglialand/or neuronal cells.

The administration of autologous mesenchymal stem cell-derived neuralprecursors to a patient includes the steps of preparing an autologousgrowth serum obtained from the patient; collecting bone marrow derivedstem cells from a patient to be treated by said method; isolating andexpanding bone-marrow-derived mesenchymal stem cells in the growthserum; culturing and isolating mesenchymal stem cell-derived neuralprecursor cells from the mesenchymal stem cells; and intrathecallyadministering said autologous mesenchymal stem cell-derived neuralprecursors to said patient. The mesenchymal stem cell-derived neuralprecursors according to the present invention exhibit an increasedamount of Nestin, neurofilament and GFAP (glial fibrillary acidicprotein) markers and a decreased amount of Vimentin marker.

The above and other features of the invention, including various noveldetails of construction and combinations of parts, will now be moreparticularly described with reference to the accompanying drawings andpointed out in the claims. It will be understood that the particulardevices and methods embodying the invention are shown by way ofillustration only and not as a limitation of the invention. Theprinciples and features of this invention may be employed in various andnumerous embodiments without departing from the scope of the invention.

BRIEF DESCRIPTION OF THE FIGURES

This patent or application file contains at least one drawing executedin color. Copies of this patent or patent application publication withcolor drawings will be provided by the Office upon request and paymentof the necessary fee.

These and other features, aspects, and advantages of the apparatus andmethods of the present invention will become better understood withregard to the following description, appended claims, and accompanyingdrawings where:

FIG. 1: Increased Neuronal and Oligodendroglial Marker Expression inMSC-Derived Neural Precursors (MSC-NP) and MSCs after in vitroDifferentiation.

Expression of β3-tubulin (neuronal marker) and O4 (earlyoligodendroglial differentiation marker) is significantly increased inMSC-NPs compared to MSCs when cultured in bFGF for 3 weeks.

FIG. 2: Increased Neuronal and Oligodendroglial Marker Expression inMSC-Derived Neural Precursors after in vitro Differentiation.

Neuronal markers (β3-tubulin and MAP-2) and oligodendroglial markers (O1and GalC) increase after 3 week differentiation in bFGF. Nestinexpression, which is a neural progenitor marker, is decreased inapproximately 50% of MSC-NPs after differentiation.

FIG. 3 graphically illustrates that MSC-derived neural precursorsdisplay anti-inflammatory characteristics similar to MSCs via theinhibition of PHA-stimulated T-cell proliferation in a co-culture.

FIG. 4: MSC-Derived Neural Precursors (MSC-NP) Lose their Capacity toDifferentiate into Mesodermal Lineages.

MSC-NPs show decreased ability to differentiate into Oil Red O positiveadipocytes (A) or calcium-containing osteocytes (B) compared to MSCs.

FIG. 5 graphically illustrates the decreased clinical score followingintravenous (A) or intracerebroventricular (B) administration of mouseMSC-derived neural precursors at the time of EAE onset (day 10) in mice.

FIG. 6: Increased Nestin Expression in MSC-Derived Neural Precursors.

(A) Spindle-shaped morphology of human MSCs isolated from bone marrowand grown in MSCGM (mesenchymal stem cell growth medium) (10% serum) asviewed by light microscopy. (B) Spherical morphology of MSC-derivedneural precursors. Neural precursors were derived from MSCs afterculturing in NPMM for 15 days. (C) Approximately 20% of human MSCsexpress Nestin protein. (D) >90% of MSC-derived neural precursorsexpress Nestin protein. Nestin protein expression was determined bystandard immunofluorescence. Cells were fixed in 4% paraformaldehyde andlabeled with Nestin antibody (Chemicon) followed by anti-rabbitsecondary antibody conjugated to Alexa-594 (Molecular Probes). PanelsA-C were viewed at 100× magnification and panel D was viewed at 200×magnification.

FIG. 7: MSC-Derived Neural Precursors (MSC-NP) show Increased ProteinExpression of Nestin, GFAP and Neurofilament-M, and Decreased Expressionof Vimentin and αSM actin compared to MSCs.

FIG. 8 graphically illustrates the increased protein expression inMSC-derived neural precursors of Nestin, GFAP and Neurofilament-M, andDecreased Expression of Vimentin and αSM actin compared to MSCs.

DETAILED DESCRIPTION

Multiple sclerosis patients typically experience progressiveneurological decline due to prolonged autoimmune attack, failure ofendogenous remyelinating mechanisms, and axonal loss. The use ofautologous MSC-derived neural precursor cells is aimed at reversing theneurodegeneration that occurs in MS through repair and regeneration ofdamaged cells. Preclinical studies in animals demonstrate that MSC-basedtherapies have significant benefit in models of CNS injury anddemyelinating disease. Clinical trial data has shown that MSCadministration is safe and well tolerated, however MSC-derived neuralprecursor cells have not been used in clinical trials. Furthermore,clinical trials with MS and ALS patients suggest that MSCs may have sometherapeutic benefit. The present invention is thus directed toelucidating the safety, tolerability, dosing and efficacy of intrathecalinjections of autologous MSC-derived neural precursor cells in MSpatients. This treatment could reverse neurodegeneration indemyelinating plaques in MS patients. Injections of MSC-derived neuralprecursor cells could also decrease the inflammatory response associatedwith MS attacks. Autologous MSC-derived neural precursor celltransplantation could serve as an effective template forneuroregeneration with minimal adverse side effects.

In vitro data suggests that pre-differentiation of MSCs into MSC-derivedneural precursors is necessary for differentiation into a more matureneuronal or glial phenotype. While differentiation of MSCs directly intoneuronal-like cells has been reported (Deng, et. al., Biochem BiophysRes Commun 282: 148-152 [2001]; Sanchez-Ramos, et. al., Exp Neurol 164:247-256 [2000]; Woodbury, et. al., J Neurosci Res 61:364-370 [2000]),these changes are likely attributed to cellular toxicity (Bertani, et.al., J Cell Sci 118: 3925-3936 [2005]; Neuhuber, et. al., J Neurosci Res77: 192-204 [2004]). Conversion of MSCs into MSC-derived neuralprecursors results in significantly increased Nestin expression (seee.g., FIG. 7), which is necessary for further differentiation intoneurons and astrocytes (Wislet-Gendebien, et. al., J Cell Sci 116:3295-3302).

The inventors of the instant application have demonstrated thatMSC-derived neural precursors, but not MSCs, are capable of in vitrodifferentiation into oligodendroglial (O4+) or neuronal (β3-Tubulin+)cell types (FIGS. 1 and 2). In addition, the present inventors havegenerated data that suggests that MSC-derived neural precursors retainthe anti-inflammatory properties of MSCs (FIG. 3), but lose theirdifferentiation plasticity (i.e. differentiation into osteoblasts oradipocytes) (FIG. 4).

These findings suggest that MSC-derived neural precursors are morelikely to respond to differentiation cues in the CNS, and in additioncan suppress the immune response and provide trophic support for damagedcells. Overall, these data support the rationale in this protocol to useMSC-derived neural precursors for cell-based therapy in multiplesclerosis.

The primary objective of the present invention was to determine thesafety and effectiveness of using autologous mesenchymal stemcell-derived neural precursor cell therapies in MS. This wasaccomplished by performing intrathecal injections of isolated andexpanded autologous MSC-derived neural precursor cells. Anotherobjective is to determine the tolerability of dosing regimens ofintrathecal administration of autologous mesenchymal stem cell-derivedneural precursor cells over different time periods.

Studies in Animal Models of Neurological Diseases

A large number of studies have shown safe and effective transplantationof MSCs into preclinical animal models of CNS disease. In vivo studiesexamining spinal cord injury in rats have shown that transplanted MSCseffectively target the injured spinal cord tissue and support axonalgrowth promoting significant clinical recovery (Chopp, et. al.,Neuroreport 11: 3001-3005 [2000]; Hofstetter, et. al., Proc Natl AcadSci USA 99: 2199-2204 [2002]; Ohta, et. al., Exp Neurol 187: 226-278[2004]; Satake, et. al., Spine 29: 1971-1979 [2004]; Zurita, Neuroreport15: 1105-1108 [2004]; Zurita, Neurosci Lett 402: 51-56). In ischemicbrain injury models in rats, transplanted MSCs migrated to the braininjury site and improved neurological outcome (Chen et. al., Am JCardiol 94: 92-95 [2004]; Lu, et. al., J Neurosurg 97: 935-940 [2002];Lu, et. al., J Neurotrauma 18: 813-819 [2001]; Lu, et. al., Neuroreport12: 559-563 [2001]). Transplantation of MSCs into multiple other modelsof neurodegenerative disease have also shown effective survival,migration, and promotion of neural networks (Bae, et. al., Stem Cells25: 1308-1316 [2007]; Hellmann, et. al., Neurosci Lett 395: 124-128[2006]), demonstrating the neuroprotective and neuroregenerativeproperties of MSCs in rodent models. Furthermore, MSCs were capable offunctional remyelination when transplanted into a demyelinated spinalcord (Akiyama, et. al., J Neurosci 22: 6623-6630 [2002]). In non-humanprimate models, preclinical evaluation of MSC implantation into the CNSof rhesus monkeys has shown cell engraftment, survival, homing to sitesof injury, and neurological benefit with no toxicity (Deng, et. al.,Cytotherapy 8: 210-214 [2006]; Isakova, et. al., Mol Ther 13: 1173-1184[2006]), suggesting that MSC-based therapies represent a safetherapeutic approach for CNS disorders.

More limited preclinical data exists for MSC-derived neural precursorsin the CNS. In a recent study 100,000 MSCs or MSC-derived neuralprecursors were transplanted intrathecally into the cisterna magna of amouse model of ALS (Habisch, et. al., J Neural Transm (in press)[2007]). The primary outcome parameter was the effect on survival time,while secondary outcome measures included improvement of motor functionand subarachnoidal and intraperenchymal cell distribution. Intrathecaltransplantation of MSCs or MSC-derived neural precursors had no effecton survival times in the ALS mice compared to untreated mice, probablydue to the lack of cell migration into the spinal cord. Interestingly,there was a significant increase in pre-symptomatic motor performance inmice receiving MSCs or MSC-derived neural precursors. There was awidespread distribution of all transplanted cells within thesubarachnoidal space, as well as significant intraparenchymal migration.This study demonstrated that MSC-derived neural precursors are toleratedas well as MSCs, and they show similar survival and migrationcharacteristics in the CNS.

Studies in Animal Models of MS

MSC administration has also been tested in mice with experimentalautoimmune encephalomyelitis (EAE), an experimental model for humanmultiple sclerosis. Experimental Autoimmune Encephalomyelitis (EAE),also called Experimental Allergic Encephalomyelitis, is an animal modelof Multiple Sclerosis. Animal models of human diseases are diseases ofnon-human species (often rodents) which closely resemble their humancounterparts and can be studied with a view to better understanding andtreating the human form. EAE is not multiple sclerosis, nor is it asingle disease in a single species, but its different forms resemble thevarious forms and stages of MS very closely in a large number of ways.

EAE is an acute or chronic-relapsing, acquired, inflammatory anddemyelinating autoimmune disease of the CNS. The animals are injectedwith the whole or parts of various proteins that make up myelin, theinsulating sheath that surrounds nerve cells (neurons). These proteinsinduce an autoimmune response in the animals—that is the animal's immunesystem mounts an attack on its own myelin as a result of exposure to theinjection. The animals develop a disease that shows pathological andclinical similarities to MS in humans.

EAE has been induced in a number of different animal species includingmice, rats, guinea pigs, rabbits, macaques, rhesus monkeys andmarmosets. For various reasons including the number of immunologicaltools, the availability, lifespan and fecundity of the animals and theresemblance of the induced disease to MS, mice and rats are the mostcommonly used species.

The animals are in-bred to reliably produce susceptibility to EAE in theanimals. As with humans and MS, not all mice or rats will have a naturalpropensity to acquire EAE. Moreover, different breeds will developdifferent forms of EAE, some of which act as good models for thedifferent human forms of MS. Different EAE forms are also used as modelsfor the different stages of MS.

Intravenous injection of MSCs in mice with EAE resulted in decreasednumber of inflammatory infiltrates, fewer demyelinating lesions, andimproved neurological function (Zappia, et. al., Blood 106: 1755-1761[2005]; Zhang, et. al., Exp Neurol 195: 16-26 [2005]). While some of theperipherally injected cells were found localized paranchemally (Zhang,et. al., Exp Neurol 195: 16-26 [2005]), the majority of MSCs wereassociated with lymphoid organs where they effectively modulate thepathogenic immune response (Zappia, et. al., Blood 106: 1755-1761[2005]; Gerdoni, et. al., Ann Neurol 61: 219-227 [2007]).

The inventors have demonstrated that injection of mouse MSC-derivedneural precursors at the time of EAE onset in mice results in a similardecrease in EAE score compared the studies described above. One millioncells were injected either intravenously or intracerebroventriclarly andthe mice were followed for 3-4 months. As illustrated in FIG. 5A, therewas a decrease in the overall level of disability of mice intravenouslyinjected with MSC-derived neural precursors compared to saline-injectedmice. When cells were injected directly into the CNS (FIG. 5B) there wassignificant delay in onset of EAE as well as decreased overalldisability.

Basis for Intrathecal Route of Administration

Preclinical animal models have been used to examine the safety andtolerability of MSCs administered via various routes. Intravenousadministration was found to be beneficial in peripheral immune-mediateddiseases, such as EAE and graft vs. host disease (GvHD) (Zappia, et.al., Blood 106: 1755-1761 [2005]; Bartholomew, et. al., Exp Hematol 30:42-48 [2002]). MSCs injected intravenously are cleared from thebloodstream after 1 hour (Koc, et. al., J Clin Oncol 18: 307-316[2000]), with the majority of cells being trapped in the lung. It hasbeen estimated that fewer than 1% of i.v. administered MSCs reach theCNS (Corti, et. al., Brain 127: 2518-2532 [2004]), making theintravenous route of administration clinically unfeasible for CNSdiseases due to the large number of cells required.

The pathological hallmark of multiple sclerosis is multi-focal,demyelinated lesions in the brain. Lesions with varying degrees ofdemyelination/remyelination are observed throughout the brain and spinalcord, although it has been noted that periventricular lesions have alesser extent of remyelination than deep white matter lesions(Patrikios, et. al., Brain 129: 3165-317260 [2006]). Most physicaldisability in MS is caused by lesions in the spinal cord, thus stemcells could be delivered directly to spinal cord lesions via intraspinalinjection. However, such a procedure would require neurosurgery andinvolves unwarranted risks to the patient. Furthermore, there aretypically multiple foci of demyelination that contribute to disability,making it difficult to deliver cells to all of the lesions. In addition,direct injections into CNS tissue would be hazardous and overlyaggressive for a non-fatal illness.

The optimal route of delivery should seed MSC-derived neural precursorsto the brain and spinal cord via the venous, arterial, or spinal fluidcirculation. Intravenous delivery of stem cells is the least invasiveroute of delivery and has been shown to be safe and tolerable for MSCs.However, IV injection of MSC-derived neural precursors would notguarantee that an adequate number of stem cells penetrate the brain andspinal cord. Therefore, we have selected an intrathecal route ofdelivery, which is minimally invasive and would seed stem cells into theCNS via cerebrospinal fluid circulation, providing potential access tospinal cord lesions and periventricular brain lesions. Preclinicalstudies demonstrating the ability of MSCs to migrate toward areascephalad to that of the injection site (Bakshi, et. al., J Neurotrama23: 55-65 [2006]; Lepore, et. al., Brain Res 1045: 206-216 [2005]),suggest that intrathecal administration via lumbar puncture is aneffective way of delivering stem cells to areas of CNS injury. Injectingmedications or cells into the CSF allows these agents to bypassextra-CNS organs and penetrate the brain rapidly. While the general flowof CSF is rostral to caudal, there is some retrograde CSF flow (Johnson,et. al., Pharm Res 22: 1011-1037 [2005]). Several efficacious treatmentsare administered intrathecally. For example, intrathecal Baclofen (ITB)is used to treat spacticity in ambulatory patients with MS. In a studyperformed by the inventors, thirty-six patients with severe spasticitywere treated with continuous infusion of ITB. Patients were followedfrom 1 to 13 years. All thirty-six patients had profound loss ofspasticity as assessed by the Ashworth scale (Sadiq, et. al., J Neurol253: 563-569 [2006]).

In models of CNS disease, MSCs have been injectedintracerebroventricularly (Ohta, et. al., Exp Neurol 187: 266-278[2004]; Amhold, et. al., Eur J Cell Biol 85: 551-565 [2006]; Chen, et.al., J Neurol Sci 189: 49-57 [2001]) and, in some cases, directly intothe pathological CNS tissues (Chopp, et. al., Neuroreport 11: 3001-3005[2000]; Hofstetter, et. el., Proc Natl Acad Sci USA 99: 2199-2204[2002]). While these routes of delivery prove efficacious in animalmodels, in humans this would translate into a highly invasive andpotentially dangerous procedure. MSCs, injected intrathecally into thelumbar region of rats after cervical spinal cord injury, migrated to andaccumulated in the area of injury (Bakshi, et. al., Neurotrauma 23:55-65[2006]), demonstrating the validity of this approach. Because of thisrostral migration of MSCs, it is inferred that MSCs are sensitive tochemotactic signaling and specific adhesion molecules (Bakshi, Et. al.,J Neurotrauma 23: 55-56 [2006]; Lapore, et. al., Brain Res 1045: 206-216[2005]). Translated to humans, the intrathecal delivery of stem cellsvia minimally invasive lumbar puncture may have significant therapeuticpotential.

In humans the first issue to be addressed is safety and tolerability.The safest route for cell delivery would be i.v. or intrathecal routes.Based on the preclinical models outlined above, the cells areadministered to human subjects cells via lumbar puncture.

In a human trial about to commence, the following procedures and stepswill be undertaken to demonstrate the efficacy of administeringautologous mesenchymal stem cell-derived neural precursors to humans totreat and/or reduce the severity of MS.

Serum Collection

Bone marrow-derived stem cells were isolated and expanded in autologousserum from the same research subject. The growth of stem cells inautologous serum prevents the introduction of potentially harmful animalproducts present in fetal bovine serum (Stute, et al. Exp Hematol 32:1212-1225 [2004]). Serum from each research subject is collected priorto the bone marrow aspiration procedure, at the enrollment visit. Ahealth professional collects approximately 200 mL of peripheral bloodfrom each research subject into tubes pre-labeled with the researchsubject's unique identifier. Patients are then given oral fluids andvital signs taken before being sent home. Blood is immediatelytransferred to the cell culture laboratory. The blood is thencentrifuged, and the serum is collected and pooled using aseptictechnique in a biosafety hood. Serum is then filtered through a 0.2 μmfilter and then stored in aliquots in a designated −80° C. freezer thatis continuously monitored by a freezer monitor with a telephone alertsystem. Each tube of serum will be labeled with the research subject'sunique identifier and the date. Each patient's serum lot will be storedin its own box also labeled with the patient's unique identifier.Materials that may contaminate or adversely affect cellular therapyproducts will not be stored in this designated freezer. Serum is used tosupport growth of autologous mesenchymal stem cells.

Bone Marrow Collection

A bone marrow aspiration is performed to obtain a bone marrow aspiratefrom the posterior iliac crest under sterile conditions followinginjection of a local anesthetic. Standard bone marrow aspirationprocedure is followed using an adult bone marrow kit with a heparinizedsyringe. For disabled patients who can not be transferred without aHoyer Lift, the iliac crest is difficult to access. These patients havethe bone marrow aspirate obtained from the manubrium of the sternum, atthe level of the second intercostal space. This procedure is performedin a wheelchair. Patients whose level of disability prevents them frombeing able to position themselves so that the hematologist can accessthe iliac crest will also have the aspirate performed from the sternum.Standard bone marrow aspiration procedure is followed using an adultbone marrow kit with a heparinized syringe. Approximately 10 cc of bonemarrow will be aspirated from each patient.

Cell Culture Reagents

A major concern in the literature regarding cell culture reagents instem cell based therapies is the use of fetal bovine serum (FBS)(Mannello, et. al., Stem Cells 25: 1603-1609 [2007]), since bovine serumantigens can remain cell associated causing an immunological reaction.The inventors have eliminated the risks associated with FBS by usingautologous serum. Nevertheless, a number of clinical trials haveinjected MSCs expanded in media supplemented FBS with no significantFBS-associated side effects (Lazarus et. al., Biol Blood MarrowTransplant 11: 389-398 [2005]; Le Blanc, et. al., Lancet 363: 1439-1441[2004]; Horwitz, et. al., Proc Natl Acad Sci USA 99:8932-8937 [2002];Bang, et. al., Ann Neurol 57: 874-882 [2005]; Mazzini, et al., NeurolSci [2007]; Mohyeddin, et. al., Iran J Immunol 4: 50-57 [2007];Karussis, et. al., J Neurol Sci [2007]). One recent study demonstratedthat patients transplanted with allogeneic MSCs developed clinicallyinsignificant anti-FBS antibodies and no MSC-specific alloantibodies(Sundin, et. al., Haematologica [2007]). In all MSC clinical trials todate, MSCs are expanded in media with FBS and L-Glut, passaged withtrypsin, resuspended in either saline or cerebrospinal fluid anddelivered intravenously (Lazarus, et al., Biol Blood Marrow Transplant11: 389-398 [2005]; Le Blanc, et. al., Lancet 363: 1439-1441 [2004];Horwitz, et. al., Proc Natl Acad Sci USA 99: 8932-8937 [2002]; Bang, et.al., Ann Neurol 57: 874-882 [2005]), intraspinally (Mazzini, et. al., JNeuro Sci [2007]), or intrathecally (Mohyeddin, et. al., Iran J Immunol4: 50-57 [2007]; Karussis, et. al., J Neurol Sci [2007]), with nosignificant side-effects associated with infusion. Similar to thesetrials, the final cell product according to the present invention isthoroughly washed and resuspended in clinical-grade saline prior tohuman injection to prevent the infusion of cell culture reagents. Ageneral description of all cell culture reagents used in this protocolis outlined herein below.

Basal Media: The basal media used to expand MSCs (MSCBM) is manufacturedin a regulatory compliant GMP facility at Lonza. The MSCBM issupplemented with Gluta-MAX (Invitrogen), which is a stable dipeptidesubstitute of L-Glutamine, an essential amino acid required for optimalcell growth. Since Gluta-MAX is metabolized by cells, noinfusion-associated toxicity is expected. Indeed, media used to growMSCs for human infusion is frequently supplemented with L-Glutamine withno apparent side effect (Lazarus et. al., Biol Blood Marrow Transplant11: 389-398 [2005]; Le Blanc, et. al., Lancet 363: 1439-1441 [2004];Horwitz, et. al., Proc Natl Acad Sci USA 99:8932-8937 [2002]; Bang, et.al., Ann Neurol 57: 874-882 [2005]; Mazzini, et al., Neurol Sci [2007];Mohyeddin, et. al., Iran J Immunol 4: 50-57 [2007]; Karussis, et. al., JNeurol Sci [2007]). MSCBM is further supplemented with 10% autologousserum. The basal media used to generate MSC-derived neural precursors(NPMM) is also manufactured in a regulatory compliant GMP facility atLonza. NPMM consists of a basal media (NPBM) with three supplements; 1)recombinant human epidermal growth factor (rhEGF), 2) recombinant humanbasic fibroblast growth factor (rhbFGF), and 3) neural cell survivalfactor (NSF-1). EGF and bFGF are each used at a final concentration 20ng/mL. Stock solutions of EGF and bFGF are provided in a saline solutioncontaining 0.1% bovine serum albumin (BSA) as a carrier protein, whichis then diluted to a final concentration of 0.0002% BSA.Mechanistically, EGF and bFGF bind to receptors on the cell surface, andreceptor-ligand complexes are then internalized and degraded inside thecell. To ensure complete removal of growth factors prior to injection ofMSC-derived neural precursors, the cells are washed thoroughly 3 timesin saline. EGF and bFGF levels were tested by ELISA during each washingstep and no significant amount of growth factor remained associated withthe final cell product. NSF-1 is a propriety formulation used to supportthe growth of neural progenitor cells. According to Lonza, a componentof NSF-1 is of bovine origin. Lonza has stated that all of itsbovine-derived products are of USDA-approved origin, thus minimizingpossible prion or viral transmission. Stock of NSF-1 is further diluted50-fold to its working concentration in the basal media.

Trypsin: MSCs are passaged each time with TrypLE (Invitrogen), amicrobially produced alternative to animal trypsin. Trypsin is a serineprotease found in the digestive system, used to cleave extracellularproteins necessary for cell attachment to the plastic dish. Trypsin ispurified from porcine pancreas, whereas TrypLE is manufactured in acontrolled fermentation process that is completely free of animal- andhuman-derived components. Prolonged exposure of trypsin (or TrypLE)leads to cell toxicity and care is taken to minimize exposure of cellsto TrypLE, which is added very briefly and then completely washed out.There is no reason to believe that TrypLE serine protease remainsassociated with the cells, as this would lead to cell toxicity.

Antibiotics: Media is supplemented with an antibiotic-antimicoticsolution (Sigma) containing penicillin, streptomycin, and amphotericin Bduring the initial culture of the mononuclear cell fraction from bonemarrow. The antibiotic-antimicotic solution is then omitted from themedia at the first cell passage and during all subsequent passages.

MSC Isolation from Bone Marrow

The research subject's sterile bone marrow sample is placed in apre-labeled bag and immediately transferred from the clinic to the stemcell culture laboratory. All handling of the bone marrow and its derivedstem cells is done in a dedicated stem cell processing laboratory underaseptic conditions in a biosafety level 2 laminar flow hood. A researchscientist transfers the bone marrow sample to a sterile 50 mL conicaltube. Mononucleated cells from the bone marrow sample are isolated bydensity gradient centrifugation. 10 mL of bone marrow sample is dilutedin 20 mL sterile Hank's Balanced Salt Solution (Sigma), layered over 15mL Ficoll-Paque PREMIUM, endotoxin-free (GE Healthcare, Life Sciences)in a separate sterile conical tube, and centrifuged at 400×g for 40minutes. The mononucleated cell layer is removed, transferred to a new50 mL conical, and washed twice by centrifugation at 100×g for 10minutes in sterile Hank's Balanced Salt Solution. At this time a trypanblue viability assay will be performed and cells will be counted. Cellsare placed into a sterile tissue culture flask (75 cm² T-flask withvented cap) in media consisting of 15 mL MSCBM (Lonza), stableL-Glutamine (GlutaMAX, Invitrogen), and 10% previously collectedautologous patient serum, and incubated at 37° C. in a 5% CO₂ humidifiedincubator. An antibiotic-antimicotic solution (Sigma) containingpenicillin, streptomycin, and amphotericin B will be added to the mediauntil the first cell passage and then omitted from the media during allsubsequent passages. All media formulations are mixed together andfiltered through a 0.2 μm filter prior to addition to cells. All mediaformulations are labeled with the appropriate unique identifier toprevent cross-contamination of reagents.

Expansion of MSCs and Cryopreservation

Culture medium is changed every 3-4 days to remove unattached(hematopoietic) cells. When the initial culture reaches 80% confluency,cells are detached from the surface by enzymatic dissociation usingTrypeLE (animal origin free trypsin, Invitrogen), washed in PBS toremove trypsin, and replated into a 150 cm² T-flask with vented cap with25 mL media, and labeled passage #1. When passage #1 MSCs reach 80-90%confluency, the cells are trypsinized again (TrypLE), counted, and300,000 cells are replated into a new 150 cm² T-flask (cell density 2000cells/cm²) and labeled passage #2. The remaining cells from passage #1(approximately 3-9 million cells) are cyropreserved in freezing mediacontaining 10% autologous serum and 10% DMSO. Cells are centrifuged(100×g for 5 minutes) and cell pellet is resuspended in freezing mediumat a concentration of 1 million cells per ml. 1 million cells (or 1 ml)is transferred to 2 mL cryovials that are labeled with each researchsubject's unique identifier. Cryovials are transferred to a dedicatedisopropanol freezing container overnight at −80° C., and then stored inliquid nitrogen. Levels of liquid nitrogen are monitored electronicallyto ensure samples are maintained at an appropriate temperature. Whenpassage #2 MSCs reach 80-90% confluency, 300,000 cells are replated intoa new 150 cm² T-flask (cell density 2000 cells/cm²) and labeled passage#3, and the remaining cells are cryopreserved. Passage #3 cells arecultured to 80-90% confluency and used for MSC characterization andquality control (see below). 500,000 passage #3 cells will also becollected for gene expression analysis (see “Quality testing of thecells” below). All MSCs used for subsequent expansion, neural precursorselection, and autologous injection are derived from either passage #1or passage #2 cryopreserved stocks.

Characterization and Quality Control

MSC cultures consist of a heterogenous population of cells, even whengenerated as single cell-derived colonies (Prockop, et al., Proc NatlAcad Sci USA 100 Suppl 1:11917-11923 [2003]). Furthermore, there are noadequate markers specific for MSCs. According to the InternationalSociety for Cellular Therapy (Dominici et. al., Cytotherapy 8: 315-317[2006]), the minimal criteria for defining human MSCs include 1) plasticadherence, 2) spindle-shaped morphology, 3) surface antigen expressionof (CD105⁺/CD73⁺/CD90⁺) and lack of expression of hematopoietic markers(CD45⁻/CD34⁻/CD14⁻/CD79⁻) and MHC (HLA-I⁻/HLA-DR⁻), and 4) in vitrodifferentiation into adipocytes, osteoblasts, and chondroblasts. Bonemarrow-derived MSCs are evaluated by this set of criteria for eachpatient. For each set of criteria, patient MSCs are compared to healthycontrol MSCs from the same passage (purchased from Lonza). Plasticadherence and morphology is evaluated and documented by an Olympus IX71inverted light microscope connected to a digital camera. Surface antigenexpression is evaluated by fluorescent immunocytochemistry, particularlyflow cytometry (BD FACS Aria) using FITC (FluoresceinIsothiocyanate)-labeled antibodies against CD105, CD73, CD90, CD45,CD34, CD14, CD79, HLA-I, and HLA-DR (all purchased from BD). Peripheralblood lymphocytes is used as a positive control for hematopoieticmarkers and Lonza MSCs is used as a positive control for MSCs. Isotypecontrols is also included. In vitro differentiation of MSCs intoadipocytes, osteoblasts, and chondroblasts is carried out using mediaand methods provided by Lonza, and compared to Lonza MSCs as well asundifferentiated controls. Adiopogenic differentiation is qualitativelyassessed by Oil Red O staining. The number of Oil Red O positive cellsis expected to be 30-100%. Subsequent to osteogenic differentiation,calcium deposition will be quantitated using StanbioTotal CalciumLiquiColor (Stanbio Labs). Expected range of calcium content in aconfluent 6-well plate is 10,000-50,000 ng/μl. Chondrogenicdifferentiation is qualitatively assessed by immunostaining sections ofparaffin embedded chondrogenic pellets for Type II collagen, indicativeof successful chondroblast differentiation. Patient MSCs must meet allof the above criteria prior to expansion of MSCs for injection andcontinuation in the study.

Expansion of MSCs from Cryopreserved Stocks

Approximately 1 month prior to stem cell injection, one vial (1 millioncells) of passage #1 or passage #2 MSCs from the research subject isremoved from liquid nitrogen storage, rapidly thawed, centrifuged toremove DMSO, and immediately plated into a 150 cm² T-flask containingcomplete medium (MSCBM supplemented with Gluta-MAX and 10% autologousserum). When cells reach 80% confluency, they are passaged exactly asdescribed above into new 150 cm² T-flasks at a density of 2000cells/cm². Cells are passaged 3-5 times further and expanded to produceup to 50 million cells.

Selection of Neural Precursor Cells from Mesenchymal Stem Cells

MSC-derived neural precursors are selected by detaching the expandedMSCs using TrypLE as described above. 500,000 MSCs are removed for geneexpression analysis (see quality testing below). 50,000 cells arere-plated in a 25 cm² T-flask for subsequent karyotype analysis (seequality testing below). Remaining cells are pooled, centrifuged, andresuspended in NPMM media from Lonza (Neural Progenitor Basal Medium,Neural Survival Factor-1, 20 ng/ml EGF, and 20 ng/ml bFGF). Cells areplated at a density of 4-6×10⁴ cells/cm² in a 75 cm² low-attachmentT-flask (BD Falcon) in 15 ml of NPMM. Culture medium is changed every2-3 days by centrifugation of floating neural precursor clusters, andresuspension in NPMM. MSC-derived neural precursors are cultured for10-15 days. Two days prior to injection, 500,000 MSC-derived neuralprecursors are removed for gene expression analysis.

Quality Testing of the Cells:

Gene expression analysis: Due to the inherent complexity in a biologicalsystem compared to a pharmaceutical product, there will be some naturalvariability in each cell product. Furthermore, the heterogenous natureof MSCs suggests that there will be some variability in gene expressionlevels between patients. With these caveats in mind, gene expressionanalysis of each patient's MSCs and MSC-derived neural precursors isperformed in order to obtain a quantitative assessment of celldifferentiation status as a reflection of each cell product's purity andpotency. Samples of 500,000 MSCs (obtained after complete expansion) and500,000 MSC-derived neural precursors (obtained two days prior toinjection date) are stored in RNA Protect (QIAGEN) at −20° C. Each batchof expanded and differentiated MSC and MSC-derived neural precursors iscompared to 500,000 MSCs obtained at passage #3 at the time ofcryopreservation. One or two days prior to injection date, RNA isextracted using RNA Easy kit (QIAGEN). 1 μg of RNA is used as templatefor cDNA synthesis (Superscript III, Invitrogen). 2 μl of cDNA templateis used as template for real-time quantitative PCR using SyBr greendetection (Roche) and previously validated gene-specific primers in aRoche Lightcycler 2.0. A positive control (human brain cDNA) is includedin each analysis, which also serves as a batch to batch calibrator. Anegative control (no DNA template) is also included each time. A noreverse transcriptase negative control is also included each time toassess for genomic DNA contamination. Samples are analyzed for RNAlevels of Nestin (a neural precursor-specific marker), Neurofilament(neuronal marker), GFAP (“glial fibrillary acidic protein”, a glial andneural precursor marker) and Vimentin (MSC marker). RPLP (60S acidicribosomal protein P0) is used as a reference gene. For each sample, thegene:RPLP ratio is determined and compared to the gene:RPLP ratio of thecalibrator sample to determine the relative expression level for eachgene. In addition, changes in gene expression for each pair of MSC andMSC-derived neural precursor samples is determined as a fold increase ordecrease in the relative gene expression level. The inventors havepreviously determined the relative ratios for each of the above genes inMSCs and MSC-derived neural precursors from 3 patient samples and 1healthy control sample (Lonza). Nestin increase in MSC-derived neuralprecursors ranges from 2-4 fold, Neurofilament increase ranges from 5-15fold, GFAP increase ranges from 7-10 fold, and Vimentin decrease rangesfrom 0.4-0.7 fold. These quantitative changes in RNA levels correlatewith changes in protein expression of these markers (FIG. 8). For eachpatient, and prior to each injection, MSC and MSC-derived neuralprecursor pairs will be analyzed for these changes in gene expressionlevels. MSC-derived neural precursors that fail to show gene expressionchanges within the expected range is discarded and not injected. In thiscase, MSCs expansion and MSC-derived neural precursor induction isrepeated starting from another cryopreserved stock. Should theMSC-derived neural precursors fail quality testing a second time, thepatient is removed from the study.

Sterility testing: 1-2 days prior to injection of autologous stem cells,cell conditioned media is tested by PCR for trace levels ofcontamination. The PCR test sensitively detects mycoplasma andeubacteria contamination of the culture. VenorGeM Mycoplasma DetectionKit is purchased from Sigma, and OnarEUB Eubacteria Detection Kit ispurchased from Minerva Biolabs. Each PCR test is carried out by atrained molecular biologist at the MSRCNY. Quality testing by PCR willinclude both positive and negative controls according to manufacturer'sinstructions. Any samples confirmed positive for contamination will bediscarded and not used for injection, and the source of contaminationwill be investigated. Possible sources of contamination include cellculture reagents, CO₂ incubator, contamination of laminar flow hood, andimproper technique. All reagents suspected as a source of contaminationare discarded, and all equipment will be cleaned. All MSC-derived neuralprecursors are confirmed negative for contamination by PCR prior toinjection into any research subject. At the same time as PCR analysis,each sample of conditioned media is sent to an outsourced company(Clongen Laboratories, LLC) for sterility testing via culture method. Inthe event that a positive result is seen, the source of infection willbe methodically investigated. In addition, the patient will bere-evaluated for signs of infection. The patient will have a CBC withdiff. If the patient does not show signs of infection a lumbar puncturewill not be performed because of the risks of the procedure.

Karyotype analysis: A sample of MSCs grown in a 25 cm² T-flask (replatedafter complete expansion) is subjected to karyotype analysis to test forany chromosome abnormalities that may arise during ex vivo expansion.The frequency of chromosomal aberrations during ex vivo expansion ofmesenchymal stem cells has been shown to be very low, occurring only inlate passage cells (Rubio, et. al., Cancer Res 65: 3035-3039 [2005]).The mesenchymal stem cells used in this protocol will all be earlypassage cells with total ex vivo culture time between 1 and 2 months,which is well within the time period where they can be managed safely(Rubio, et. al., Cancer Res 65: 3035-3039 [2005]). Results fromkaryotype analysis is obtained prior to injection of MSC-derived neuralprecursors. Should any karyotype abnormality be determined in theexpanded MSCs, the corresponding MSC-derived neural precursors isdiscarded and not injected.

Experimental

Nestin protein expression in MSC-derived neural precursors

Nestin protein expression was determined by standard immunofluorescence.Cells were fixed in 4% paraformaldehyde and labeled with Nestin antibody(Chemicon) followed by anti-rabbit secondary antibody conjugated toAlexa-594 (Molecular Probes). FIG. 6 illustrates the increased nestinexpression in MSC-derived neural precursors. The neural precursors inpanel B were derived from MSCs after culturing in Neural ProgenitorMaintenance Media (NPMM). Panels A-C of FIG. 6 was viewed at 100×magnification and panel D was viewed at 200× magnification.

Changes in Gene Expression of Neural Precursor Cells from MSCs

MSC culture was expanded in mesenchymal stem cell growth medium (MSCGM)for 4 passages. MSC-NPs were selected from MSCs by culturing for 15 daysin NPMM. Cells were plated in PDL/Laminin-coated 8-well slides andassayed 18 hours later for protein expression by standardimmunofluorescence. Cells were immunolabeled with antibodies againstNestin (1:2000), GFAP (1:500), Neurofilament-M (NF-M, 1:1000), Vimentin(1:5000), alpha smooth muscle isoform of actin (actin αSM, 1:1000), allpurchased from Chemicon. Secondary antibodies against mouse IgG orrabbit IgG conjugated to Alexa-594 were from Molecular Probes. Secondaryantibody alone was included as a control. Labeled cells were mountedwith DAPI and viewed with an Olympus BX60 fluorescent microscope under200× magnification. The increased protein expression of nestin, GFAP,and neurofilament-M, and decreased expression of Vimentin and αSM actinin MSC-derived neural precursors compared to MSCs is shown in FIGS. 7and 8.

In Vitro Differentiation of MSC-Derived Neural Precursors

MSC-NPs were differentiated into neuronal and oligodendroglial celltypes in vitro. MSC-NPs were selected from MSCs by culturing for 15 daysin NPMM. Cells were plated in matrigel-coated 8-well slides and culturedin either basic medium alone (control), or containing 100 ng/ml bFGF for21 days. Cells were fixed in 4% paraformaldehyde and immunolabeled withprimary antibodies against class III β-tubulin (1:100), microtubuleassociated protein-2 (MAP-2, 1:100), oligodendrocyte marker 04 (1:200),oligodendrocyte marker O1 (1:1000), Galactocerebroside (GalC, 1:50), andNestin (1:1000), all from Chem icon. Fluorescently conjugated secondaryantibodies against mouse IgG or IgM (Alexa594) or rabbit IgG (Alexa-488)were from Molecular Probes. Labeled cells were mounted with DAPI andviewed with an Olympus BX60 fluorescent microscope under 200×magnification. FIGS. 1 and 2 illustrate the increased neuronal andoligodendroglial marker expression in MSC-derived neural precursors(MSC-NP) and MSCs after in vitro differentiation.

Anti-Inflammatory Characteristics of MSC-Derived Neural Progenitors

CFSE-labeled allogeneic T cells from peripheral blood were stimulatedwith PHA (Phytohemagglutinin) for 4 days. T cells were cultured alone,or co-cultured with human MSCs from donor 1) or MSC-derived neuralprecursors from donor 1 and from donor 2. T cells proliferation wasmeasured by FACS analysis based on decreased CFSE fluorescence of CD3+cells. The anti-inflammatory display of the MSC-derived neuralprecursors is illustrated in FIG. 3.

MSC-Derived Neural Precursors Loss of Differentiation Capacity

For adipogenic induction, MSCs or MSC-NPs were cultured in either MSCGM(control) or adipocyte induction media containing insulin,dexamethasone, indomethacin, and IBMX for 3 weeks. Cells were fixed andlipid vacuoles were stained with Oil Red O. For osteogenic induction,MSCs or MSC-NPs were cultured in either MSCGM (control) or osteocyteinduction media containing dexamethasone, ascorbic acid, andβ-glycerophosphate for 3 weeks. Total calcium deposition was assayed byCalcium (CPC) Liquicolor kit (Stanbio Laboratory). The loss in capacityof the MSC-derived neural precursors to differentiate into mesodermallineages is shown in FIG. 4.

Preparation of Autologous Stem Cells for Injection

Prior to injection, MSC-derived neural precursors are pooled andcollected by centrifugation. Cell clusters are broken up into a singlecell suspension by incubation with TrypLE for 5 minutes at roomtemperature. Cells are washed three times in sterile, injection grade0.9% Sodium Chloride, USP to remove any traces of media and growthfactors. A total of 10 million cells are resuspended in 0.2 ml ofsterile, injection grade 0.9% Sodium Chloride USP, transferred to asmall sterile tube, and placed into a labeled, sterile container fortransport to the IMSMP. 10 million cells is a relatively low dose ofcells and was calculated using averages from animal and human trials.

Injection of Autologous Stem Cells

Patients received intrathecal injections of the isolated and expandedstem cells under sterile conditions following standard procedure. Asterilized LP tray was used. A sterile field was established, and 1%lidocaine was used as a local anesthetic. The primary investigatoraspirated 6 mL of CSF at the L3-L4 level using a 25 gauge needle. Astandard LP kit has a 20 gauge needle however in this study a 25 gaugeneedle will be used to lower the incidence of headaches associated withspinal taps. If access is limited at the L3-L4 level, the L2-L3 levelwill be used as an alternative site. The stem cells are added to 3 mL ofCSF, and the CSF and stem cell mixture is injected intrathecally, andthen chased by an additional 3 mL of CSF. This procedure takesapproximately 30 minutes. Immediately following this procedure, thepatient is infused with 80 mgs of Tobromycin and 500 mgs of Vancomycin(McKesson Corporations). This infusion takes approximately four hours.Vancomycin is the drug of choice for S. epidermidis, which would be acontaminant from the skin during the lumbar puncture procedure. It isalso the drug used to treat penicillin resistant S. pneumoniae.Vancomycin is also indicated in empiric use in meningitis until anorganism has been identified. Tobromycin is synergistic with Vancomycinand is also the treatment of choice for pseudomonas infections. AlsoVancomycin and Tobramycin are indicated in empiric use to treatmeningitis in all neurosurgical procedures at most intuitions (TheManual of Medical Therapeutics, 30^(th) Edition). Injections occur everythree months and patients undergo three rounds of treatment. Thetreatment phase of this study will take 9 months and patients will befollowed for 12 months after the third (final) treatment. This is anadequate amount of time for cells to integrate and for any problems withsafety and tolerability to become apparent.

Dosing Schedule for Humans

Autologous stem cell injections occur at three month intervals over thecourse of nine months. 10 million MSC-derived neural precursors will beinjected at each treatment. This dose was calculated based onpreclinical safety data where 2.5×10⁶ (Black, et. al., Blood Cells MolDis 27: 632-636) cells bone marrow-derived MSCs were engrafted into theCNS of healthy rhesus macaques with no adverse effects evaluated over a6-month period (Isakova, et. al., Mol Ther 13: 1173-1184 [2006]). TheHED (http://www.fda.gov/cber/gdlns/dose.htm) was calculated to be1.5×10⁵ (Woodbury, et. al., J Neurosci Res 69: 908-917) cells/kg orapproximately 10 million cells per patient. This dose was safe and welltolerated in the MS clinical trial conducted in Iran (Mohyeddin, et.al., Iran J Immunol 4: 50-57 [2007]). Patients received intrathecalinjections of 2.5 million to 13 million MSCs. A dose of ten millioncells is also considered a low dose compared to intraspinal delivery ofMSCs in the ALS trial (ranged 7-150 million cells) (Mazzini, et. al.,Neurol Res 28: 523-526 [2006]). Preclinical studies have concluded thata low dose of cells injected multiple times is more effective thansingle high dose injections (Bakshi, et. al., J Neurotrama 23: 55-65[2006]; Lepore, et. al., Brain Res 1045: 206-216 [2005]), which isconsistent with our study design. Immediately following cell infusion,patients will also receive an infusion of 80 mgs of Tobromycin and 500mgs of Vancomycin. This medication will be supplied by McKessonCorporation.

The cells are manufactured following all Good Manufacturing Practiceregulations. Cells are cryopreserved in media containing 10% autologousserum and 10% DMSO in 2 ml cryovials. Cryovials are labeled with eachresearch subject's unique identifier and stored in liquid nitrogen, witheach serum lot stored in a separately labeled box. Storage location foreach sample is recorded in a database, which is backed up by hardcopy.Levels of liquid nitrogen are monitored electronically to ensure samplesare maintained at an appropriate temperature. All mesenchymal stem cellsused for subsequent expansion, neural precursor selection, andautologous injection are derived from cryopreserved stocks. There is noevidence that cells stored in liquid nitrogen in an undisturbed mannerlose either in vitro determined viability or biological activity.Therefore, no expiration date need be assigned to MSCs storedcontinuously in liquid nitrogen. Approximately 1 month prior to stemcell injection, mesenchymal stem cells from the research subject areremoved from liquid nitrogen storage and expanded in Mesenchymal StemCell Basal Medium containing autologous serum, as described above. Cellsare passaged 3-5 times in tissue culture flasks and expanded to produce50 million cells. MSCs are subsequently cultured in Neural ProgenitorMaintenance Medium for 10-15 days to generate MSC-derived neuralprecursors.

While there has been shown and described what is considered to bepreferred embodiments of the invention, it will, of course, beunderstood that various modifications and changes in form or detailcould readily be made without departing from the spirit of theinvention. It is therefore intended that the invention be not limited tothe exact forms described and illustrated, but should be constructed tocover all modifications that may fall within the scope of the appendedclaims.

What is claimed is:
 1. A method for the in vitro differentiation ofmesenchymal stem cells and selection of neural precursors derivedtherefrom, the method comprising the steps of: (a) isolating mesenchymalstem cells from a human, (b) expanding the isolated mesenchymal stemcells, (c) culturing a portion of said expanded mesenchymal stem cellsin a neural progenitor basal medium (NPBM) supplemented with epidermalgrowth factor (EGF), basic fibroblast growth factor (bFGF), and neuralcell survival factor-1 (NSF-1), (d) collecting floating cell clustersfrom the NPBM-cultured cells, (e) measuring, in a test portion of thecollected cells, expression of nestin, glial fibrillary acidic protein(GFAP), neurofilament-M (NF-M), and alpha smooth muscle (αSM) actin,relative to expression of nestin, GFAP, NF-M, and αSM actin in a testportion of the mesenchymal stem cells expanded in step (b), and (f)selecting the remaining portion of the collected cells as neuralprecursors for further use based on increased expression of nestin,GFAP, and NF-M, and decreased expression of αSM actin in said testportion of the collected cells, relative to the expression of nestin,GFAP, NF-M, and αSM actin in said test portion of mesenchymal stemcells.
 2. The method of claim 1, wherein the mesenchymal stem cells areexpanded in step (b) in mesenchymal stem cell basal medium comprisingautologous serum.
 3. The method of claim 1, wherein the culturing ofstep (c) is performed for 10-15days.
 4. The method of claim 1, furthercomprising: (g) culturing the cells selected in step (f) in a mediumcomprising basic fibroblast growth factor, thereby furtherdifferentiating mesenchymal stem cell-derived neuronal precursors. 5.The method of claim 4, wherein the medium comprising basic fibroblastgrowth factor for the culturing of step (g) comprises 100ng/ml basicfibroblast growth factor.
 6. The method of claim 4, wherein theculturing of step (g) comprises changing the medium every 2-3 days for21 days.
 7. The method of claim 6, wherein the human has multiplesclerosis.
 8. The method of claim 1, wherein if the test portion of thecollected cells do not show increased expression of nestin, GFAP, andNF-M, and decreased expression of αSM actin in said test portion of thecollected cells, relative to the expression of nestin, GFAP, NF-M, andαSM actin in said test portion of mesenchymal stem cells, steps (c)through (d) are repeated using another portion of mesenchymal stem cellsexpanded in step (b).